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Hand and Wrist Anatomy

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Title: Hand and Wrist Anatomy


1
Hand and Wrist Anatomy
  • 14 phalanges
  • 2 sesamoid bones (thumb)
  • 5 metacarpals
  • 8 carpal bones
  • Distal Radius
  • Forms small ulnar notch to accept the ulnar head
  • Radial styloid process
  • Distal Ulna
  • Ulnar styloid process arises from medial surface
  • Ulnar head

2
  • Carpals(flat bones aligned in 2 rows)
  • Proximal
  • Scaphoid-most commonly fractures
  • Lunate-most commonly dislocated
  • Triquetrum
  • Pisiform-acts as sesmoid bone
  • Distal
  • Trapezium(aligns with 1st metacarpal)
  • Trapezoid(2nd metacarpal)
  • Capitate(3rd metacarpal)
  • Hamate(4th and 5th metacarpal)

3
Articulations
  • Distal Radioulnar
  • Formed by ulnar head and ulnar notch
  • Allows 1 degree freedom of movement
  • Pronation/supination
  • Radius glides around the ulna

4
  • Radiocarpal joint
  • Reinforced by ligamentous thickening
  • Formed by distal radius articulating with
    scaphoid, lunate and triangular fibrocartilage
    disk(TFCC)
  • Ellipsoid joint (2 degrees freedom)
  • Flexion/extension
  • Radial/ulnar deviation

5
  • Intercarpal Joints
  • Palmar/dorsal/interosseous ligaments between each
    carpal
  • Very little gliding

6
  • Midcarpal Joints
  • Proximal/distal carpal row separated by a single
    joint cavity with small fibrous projections
    connecting the rows
  • Limited mobility in flex/ext, radial/ulnar
    deviation

7
  • Carpometacarpal Joint (CMC)
  • MC1/trapezium
  • MC2/trapezoid
  • MC3/capitate
  • MC4and 5/hamate (forms 1 articulation)

8
  • 1st CMC (thumb)
  • Saddle joint
  • 2 degrees of freedom(3)
  • Flexion/extension
  • Abduction/adduction
  • Accessory rotation
  • Allows for opposition

9
  • 2-4 CMC
  • Plane/synovial joint
  • 1 degree freedom
  • Flexion/extension
  • 5th CMC
  • 2 degree freedom
  • Flexion/extension
  • Abduction/adduction

10
  • Metacarpophalangeal Joint (MCP)
  • Two degrees freedom of movement
  • Flexion/extension
  • Abduction/adduction
  • Thumb can abduct at any point/fingers only when
    extended
  • Collateral ligaments
  • Varus/valgus force
  • When fingers are in flexion they tighten and
    limit abduction/adduction

11
  • Interphalangeal Joint
  • One degree freedom of movement
  • Flexion/extension
  • Collateral ligaments

12
Muscular Anatomy
  • Wrist Extensors (innervated by radial n.)
  • Superficial
  • Extensor carpi radialis brevis/longus
  • Extensor carpi ulnaris
  • Extensor digitorium
  • brachioradialis
  • Deep compartment
  • Extensor pollicus longus/brevis
  • Abductor pollicus longus
  • Extensor indices
  • supinator
  • Secured by extensor retinaculum

13
  • Wrist flexors (median n.)
  • Superficial
  • Flexor carpi radialis
  • Palmaris longus
  • Flexor carpi ulnaris
  • Flexor digitorium superficialis
  • Pronator teres
  • Deep
  • Flexor digitorium profundus
  • Flexor pollicis longus
  • Pronator quadratus

14
  • Palmar (intrinsic)
  • Thenar
  • Abductor pollicis brevis
  • Flexor pollicis brevis
  • Opponens Pollicis
  • Tendon FPL
  • Adductor pollicis

15
  • Hypothenar
  • Abductor digiti minimi
  • Opponens digiti minimi
  • Flexor digiti minimi brevis

16
  • Central
  • Tendons FDS/FDP
  • Superficialis (PIP)
  • Profundus (DIP)
  • Lumbricales
  • Radial side profundus tendon(extensor hood)
  • Flex MP/ext PIP/DIP
  • Palmar aponeurosis
  • Interossei
  • 4 palmar/4 dorsal

17
Carpal Tunnel
  • Fibro-osseous structure
  • Floor is proximal carpal bones
  • Roof is transverse carpal ligament
  • Tunnel contains 10 structures
  • Median n., flexor pollicis longus tendon, 4 slips
    of flexor digitorium superficialis, flexor
    digitorium profundus
  • Compression results in paresthesia 2-4 fingers
    and decrease grip

18
  • Wrist and Hand Evaluation

19
History
  • Location of pain
  • Mechanism of injury
  • Relevant sounds/sensations
  • Duration of symptoms
  • Description of symptoms
  • Previous history
  • General medical health

20
Inspection
  • General
  • Posturing of hand
  • Gross deformity
  • Palmar Creases
  • Areas of lacerations or scars
  • Wrist
  • Continuity of distal radius and ulna
  • Continuity of carpals/metacarpals
  • Lunate dislocation
  • Alignment of MCP joint
  • Posture of wrist and hand
  • Ganglion cyst
  • Volkmans Contracture
  • Finger Deformities

21
Inspection
  • Hand
  • Alignment of knuckles
  • Depressed(metacarpal fracture)
  • Alignment of fingernails
  • Spiral fracture
  • Boutonniere deformity
  • Flex PIP, ext MP/DIP
  • Mallet finger
  • Inability to extend distal phalanx
  • Avulsion of extensor tendon 25-35 flexion DIP
  • Jersey Finger
  • Ruptured FDP-inability to flex DIP

22
Palpation
  • Anteromedial
  • Ulnar head
  • Ulnar styloid process
  • UCL-(styloid, triquetrum and pisiform)
  • Pisiform
  • Triquetrum
  • Hamate
  • Wrist flexor group
  • Flexor Carpi Ulnaris
  • Flexor Digitorium Profundus
  • Palmaris Longus
  • Flexor carpi radialis
  • Carpal Tunnel

23
  • Posterolateral
  • Radial shaft
  • Distal radius and styloid process
  • Radial collateral ligament
  • Scaphoid(Anatomical snuff box)
  • Extensor Carpi Radialis Longus
  • Extensor Digitorium
  • Extensor Carpi Ulnaris
  • Thumb extensors (EPL, EPB)

24
  • Bony
  • Carpals
  • scaphoid
  • Metacarpals
  • Phalages
  • Ulna
  • Radius
  • Listers Tubercle

25
Palpation
  • Hand
  • Collateral ligaments of MCP(1-5)
  • Phalanges
  • Collateral ligaments of IP joints
  • Thenar compartment
  • Thenar webspace
  • Central compartment
  • Hypothenar eminence

26
  • Wrist AROM (2 degrees)
  • PROM
  • RROM
  • Ligamentous/Capsular Testing
  • Neurologic Testing
  • Special Tests

27
Wrist Goniometry
  • Flexion and Extension
  • Patient
  • Forearm pronated with hand off edge of table
  • Fulcrum
  • Over lateral joint line of wrist
  • Stationary Arm
  • Centered midline of ulnar shaft
  • Movement Arm
  • Centered on midline of 5th metacarpal

28
  • Radial and Ulnar Deviation
  • Patient
  • Forearm is pronated with hand resting on table
  • Fulcrum
  • Aligned with the center of distal radioulnar
    joint just proximal to capitate
  • Stationary Arm
  • Centered over midline of forearm
  • Movement Arm
  • Centered over 3rd metacarpal

29
  • Wrist AROM
  • 2 degrees
  • Sagittal plane
  • Flexion (80-90)
  • Extension (75-85)
  • Fingers relaxed to ensure maximum ROM
  • Frontal plane (in neutral)
  • Radial (20)
  • Ulnar deviation (35)

30
  • PROM
  • Flexion firm end point
  • Extension firm end point
  • Radial deviation hard (scaphoid/styloid)
  • Ulnar deviation firm end point

31
  • RROM
  • Flexion/extension
  • Radial/ulnar deviation

32
  • Finger A/P/RROM MCP joint
  • Flexion/extension MCP (105-135)
  • Flexion hard end feel
  • Extension firm
  • Abduction/adduction MCP (20-25)
  • Abduction firm
  • Flexion/extension IP
  • Test each finger individually

33
Wrist Special Tests
  • Valgus and Varus Test
  • Patient
  • Sitting with elbow flexed to 90 deg, forearm
    pronated
  • Examiner
  • One hand grips distal forearm other grasps hand
    across metacarpals
  • Procedure
  • UCL Valgus stress is applied (radially deviated
    wrist)
  • RCL Varus stress is applied (ulnarly deviate
    wrist
  • Positive Test
  • Pain or laxity
  • Implications

34
  • Wrist Glide
  • Patient
  • Sitting, elbow flexed to 90 deg, forearm pronated
  • Examiner
  • One hand grasps distal radius, other grasps
    proximal carpal row
  • Procedure
  • Shear force is applied to wrist by gliding distal
    segment in a radial and ulnar direction and then
    in a volar and dorsal direction
  • Positive Test
  • Pain or significant change in glide
  • Implications

35
  • Ligamentous/capsular testing for fingers
  • Valgus/Varus
  • Full extension IP
  • MCP-thumb
  • Ulnar colateral (valgus)
  • RCL of little finger

36
  • Murphys sign
  • Patient makes a fist
  • If the head of the third metacarpal is level with
    the 2nd and 4th metacarpal, sign is positive for
    lunate dislocation

37
  • Finkelsteins test
  • Patient
  • Seated or standing
  • Procedure
  • Tucks thumb under fingers by making a fist
  • Ulnarly deviate wrist
  • Positive test
  • Increased pain over radial styloid process and
    length of extensor pollicis brevis and abductor
    pollicis longus
  • Implication
  • deQuervians syndrome

38
  • Neurologic Testing
  • Special tests
  • Drop wrist syndrome
  • Inability to extend wrist (radial n.)
  • Tinels sign

39
  • Phalens Test
  • Patient
  • Standing or seated
  • Procedure
  • Examiner applies overpressure during passive
    wrist flexion and holds for 1 minute
  • Positive Test
  • Tingling in distribution of median n.
  • Implications
  • Median Nerve Compression

40
  • Vascular Occlusion
  • Allens test
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